Unit B
Resident Care Skills
Essential Standard NA4.00
Understand nurse aide skills related to the residents’ vital function and movement
Indicator 4.01
Understand vital signs, height, and weight skills.
Understanding vital
signs, height, and
weight measurement
skills.
4.01
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F Y I - Intentional Repeat
There is intentional repeat of some HSII
course content in Nursing Fundamentals.
Repeating course content distributes learning
over time and increases long term memory.
Academic and skill competence must be
maintained at a very high level for direct
resident care.
4.01
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Introduction
Indicator 4.01 introduces
skills the nurse aide will need
to measure and record the
resident’s vital signs, height
and weight.
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Vital Signs
provide information
about changes in
normal body function
and the resident’s
response to treatment.
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Vital Signs
Often the
FIRST
sign that
there is a
problem!
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TPR+BP = Vital Signs
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TPR+BP = Vital Signs
• Reflect the function of three body
processes that are essential for life.
–Regulation of body temperature
–Heart function
–Breathing
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TPR+BP = Vital Signs
• Abbreviations:
–Temperature – T
–Pulse – P
–Respirations – R
–Blood Pressure – BP
–Vital signs - TPR and BP
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TPR+BP = Vital Signs
• Purpose
–Measured to detect
any changes in
normal body
function
–Used to determine
response to
treatment
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TPR+BP = Vital Signs
Temperature
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TPR+BP = Vital Signs
Temperature
• Heat production
–muscles
–glands
–oxidation of
food
4.01
• Heat loss
–respiration
–perspiration
–excretion
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TPR+BP = Vital Signs
Temperature
Balance between heat
production and heat loss is body
temperature
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Factors Affecting Temperature
•
•
•
•
•
4.01
Exercise
Illness
Age
Time of day
Medications
•
•
•
•
•
Infection
Emotions
Hydration
Clothing
Environmental
temperature/air
movement
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Equipment - Thermometer
• Instrument used to measure body
temperature
• Types
–Non-mercury glass
• oral
• rectal
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Equipment - Thermometer
• Types (continued)
–chemically treated paper –
disposable
–plastic – disposable
–electronic - probe covered with
disposable shield
–tympanic - electronic probe used in
the ear
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Electronic Thermometers
Electronic
Can be used for oral,
rectal, or axillary
Blue probe for oral
Red probe for rectal
Disposable probe covers
prevent crosscontamination
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Aural/Tympanic Temperature
- taken in the ear
- measures the thermal
infrared energy
radiating from the blood
vessels in the eardrum
- position and ear wax
can affect readings
-left in until it beeps
-temperature is
calculated into an
equivalent by mode
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Positioning the Patients Ear for
Tympanic temperature
• Infants under 1 year
– Pull ear pinna straight back
• Infants over 1 year and
adults
– Pull ear pinna straight back
and down
• Positioning the pinna
correctly straightens the
auditory canal so the probe
will point directly at the
tympanic membrane
– Pull ear pinna straight back
and down
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Placement of the Oral
Thermometer
Put the bulb tip
of the
thermometer in
the “hot
pocket” under
the tongue.
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Normal Temperature Range For Adults
• Oral - 97.6 - 99.6 F
(Fahrenheit) or 36.5 37.5 C (Celsius)
• Rectal - 98.6 - 100.6 F
or 37.0 - 38.1 C
• Axillary - 96.6 - 98.6 F
or 36.0 - 37.0 C
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“Tic-Tac-Know”
Normal Range For Adult Temperature
FREE SPACE
98.6°F is the FREE SPACE
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
98.6°F
98.6°F is the average oral temperature
for adults and it falls in the middle of the
normal range.
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
98.6°F 99.6°F
Add one degree to 98.6°F then place the
results in the oral space to the right
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
97.6
98.6
99.6
Subtract one degree from 98.6 then place
the results in the oral space to the left
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
97.6°
98.6
99.6
The average adult temperature taken
orally is 98.6° F and the
RANGE is 97.6° F to 99.6° F.
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“Tic-Tac-Know”
Normal Range For Adult Temperature
Body heat REGISTERS one degree warmer when the
temperature is taken RECTALLY ®. Add one degree to
98.6°F then place the results in the space below 98.6°F
ORAL
RECTAL
4.01
97.6°F 98.6°F 99.6°F
99.6°F
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
RECTAL
97.6°F 98.6°F
99.6°F
99.6°F 100.6°F
Add one degree to 99.6°F then place the results in the
rectal space to the right.
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
97.6°F 98.6°F
RECTAL 98.6
99.6°F
99.6°F 100.6°F
Subtract one degree from 99.6°F then place the
results in the rectal space to the left.
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“Tic-Tac-Know”
Normal Range For Adult Temperature
ORAL
97.6°F 98.6°F
RECTAL 98.6
99.6°F
99.6°F 100.6°F
The average adult temperature taken RECTALLY is
99.6° F and the
RANGE is 98.6° F to 100.6° F.
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“Tic-Tac-Know”
Normal Range For Adult Temperature
Body heat REGISTERS one degree COOLER when the temperature
is taken AXILLARY (Ax) or in the GROIN. Subtract one degree from
98.6°F then place the results in the space above 98.6°F
AXILLARY
or GROIN
ORAL
RECTAL
4.01
97.6
97.6°F 98.6°F
98.6
99.6°F
99.6°F 100.6°F
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“Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY
or GROIN
ORAL
RECTAL
97.6°F
97.6°F 98.6°F
98.6
98.6
99.6°F
99.6°F 100.6°F
Add one degree to 97.6°F then place the results to the right
of 97.6°F
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“Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY
or GROIN
ORAL
RECTAL
96.7°
97.6°F
97.6°F 98.6°F
98.6
98.6
99.6°F
99.6°F 100.6°F
Subtract one degree from 97.6°F then place the results to
the left of 97.6°F
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“Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY
or GROIN
ORAL
RECTAL
96.7°
97.6°F
97.6°F 98.6°F
98.6
98.6
99.6°F
99.6°F 100.6°F
YOU MUST RECORD THE LOCATION WHERE THE
TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !
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“Tic-Tac-Know”
Normal Range For Adult Temperature
AXILLARY (Ax) or
Groin
or GROIN
ORAL
RECTAL
O
<Pic of
Groin>
If no location is
indicated, the oral
route is assumed
(R)
YOU MUST RECORD THE LOCATION WHERE THE
TEMPERATURE WAS TAKEN IN ORDER TO INTERPRET
NORMAL FROM ABNORMAL !
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To Read A Non-mercury Glass
Thermometer
• Hold eye level
• Locate solid column of liquid in the
glass
• Observe lines on scale at upper
side of column of liquid in the glass
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To Read A Non-mercury Glass
Thermometer
(continued)
• Read at point where liquid ends
• If liquid falls between two lines, read it
to closest line
–long line represents degree
–short line represents 0.2 of a degree
Fahrenheit
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Sites To Take A Temperature
• Oral – most common
• Rectal – registers one degree
Fahrenheit higher than oral
• Axillary – least accurate; registers
one degree Fahrenheit lower than
oral
• Tympanic – probe inserted into the
ear canal
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Sites To Take A Temperature
(continued)
Condition of resident
determines which is the
best site for measuring
body temperature
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Temperature: Safety Precautions
• Hold rectal and axillary thermometers
in place
• Stay with resident when taking
temperature
• Check glass thermometers for chips
• Prior to use, shake liquid in glass
down
• Shake thermometer away from
resident and hard objects
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Temperature: Safety Precautions
(continued)
• Wipe from “handle” end
toward bulb tip of
thermometer prior to
reading
• Delay taking oral
temperature for 10 - 15
minutes if resident has
been smoking, eating or
drinking hot/cold liquids.
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Temperature Conditions
• Hyperthermia
– Increased body temp
– Body temp >104ºF
– >106 ºF will cause
convulsions and
death
• Fever
- temp over 101 ºF R
- Due to illness or
injury
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Temperature Conditions
• Hypothermia
– Body temp below
– 96 ºF
– due to exposure to
cold temperatures
– Depends on core
temperature, age
and length of
exposure
4.01
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01A
Oral temperature using a non-mercury
glass thermometer
4.01
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01B
Axillary temperature using a
non-mercury glass thermometer
4.01
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01C
Rectal Temperature using a
non-mercury glass thermometer
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01Dto
Measure Temperature with
Electronic Thermometer
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01E
Measure Temperature with
Tympanic Thermometer
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PR+BP = Vital Signs
T
PULSE
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PULSE
Measuring the pulse is one way of
checking on the circulatory system
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Circulatory System
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Circulatory System
• Circulation is
continuous
movement of blood
throughout body
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Circulatory System
(continued)
• Functions of circulatory system
–Arteries carry blood with
oxygen and nutrients away
from heart and to cells
–Veins carry waste products
away from cells and to heart
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Blood
• Adult has 5 to 6 quarts (liters)
• Consists of
–water - 90% (plasma)
–blood cells
–carbon dioxide and oxygen
–nutrients, hormones and
enzymes
–waste products
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Blood
(continued)
• Types of blood cells
–Red blood cells - erythrocytes
• carry oxygen from blood to cells
–White blood cells - leukocytes
• fight infection
–Platelets - thrombocytes
• required for clotting to stop
bleeding
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Blood Vessels
• Arteries - carry blood away from heart
• Veins – carry blood to heart
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Heart
• Tissue (three layers)
–endocardium - smooth,
inner layer
–myocardium – thick,
muscular middle layer
–pericardium – doublewalled membrane that
covers outside of heart
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Heart Chambers
• Heart divided into
right and left side
• Atria – upper
chambers –
receive blood
• Ventricles –
lower chambers
– pump blood to
lungs and body
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Heart Chambers
• Four chambers
–right atrium (1) - receives
blood from two large veins:
• superior vena cava
• inferior vena cava
–right ventricle (2) - receives blood
from right atrium and pumps it to
lungs through pulmonary artery
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Heart Chambers
(continued)
• Four chambers
–left atrium (3) - receives
oxygenated blood from left
and right pulmonary veins
–left ventricle (4) - pumps
blood to aorta, which
delivers blood to all body
parts (except lungs)
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Heart Valves
• Located at entrance and exit of each
ventricle
• Four heart valves
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Heartbeat
• Systole - contraction of heart muscle
• Diastole - relaxation of heart muscle
• Blood pressure – highest and lowest
pressure against walls of blood
vessels as heart contracts and
relaxes
• Pulse - expansion and contraction of
artery
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Common Disorders of the
Circulatory System
• Arteriosclerosis - walls of arteries
become thick and harden
• Hypertension - high blood pressure
• Peripheral vascular disease decrease in flow of blood to
extremities and brain
• Angina pectoris - chest pain
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Common Disorders of the
Circulatory System
(continued)
• Varicose veins - enlarged, twisted
veins usually in legs
• Congestive heart failure circulatory congestion caused by
weak pumping of heart muscle
• Myocardial infarction (MI) - heart
attack due to blockage in coronary
arteries
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Common Disorders of the
Circulatory System
(continued)
•
•
•
•
Anemia – low red blood cell counts
Thrombus – blood clot
Phlebitis – inflammation of vein
Atherosclerosis - fatty deposits on
walls of arteries that reduce blood
flow
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Changes of the Circulatory System
Due To Aging
• Heart muscle less efficient
• Blood pumped with less force
• Arteries lose elasticity and
become narrow
• Blood pressure increases
• Blood chemistry less efficient
• Capillaries become more fragile
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Observations of the Circulatory
System
• Changes in pulse rate and
blood pressure
• Changes in skin color
• Changes in skin
temperature – coldness
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Observations of the Circulatory
System
(continued)
• Complaint of dizziness and
headaches
• Complaint of pain in chest
and/or indigestion
• Edema in feet and legs
• Shortness of breath
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Observations of the Circulatory
System
•
•
•
•
•
•
•
•
(continued)
Sweating
Blue color to lips and/or nail beds
Complaint of tingling sensations
Memory lapses
Lack of energy
Irregular respirations
Anxiety
Staring and lack of responsiveness
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PR+BP = Vital Signs
T
PULSE
• Pulse is pressure of
blood pushing against
wall of artery as heart
beats and rests
• Pulse easier to locate
in arteries close to
skin that can be
pressed against bone
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Sites For Taking Pulse
• Radial – base of thumb
• Temporal – side of
forehead
• Carotid – side of neck
• Brachial – inner aspect
of elbow
• Femoral – inner aspect
of upper thigh
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Sites For Taking Pulse
(continued)
• Popliteal - behind knee
• Dorsalis pedis – top of
foot
• Apical pulse – over apex
of heart
–taken with stethoscope
–left side of chest
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Factors Affecting Pulse
•
•
•
•
•
•
•
•
•
4.01
Age
Sex
Position
Drugs
Illness
Emotions
Activity level
Temperature
Physical training
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Measurement of Pulse
• Normal pulse range/characteristics:
60 -100 beats per minute and regular
• Documenting pulse rate
–Noted as number of beats per
minute
–Rhythm - regular or irregular
–Volume - strong, weak, thready,
bounding
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01F
Count and Record
Radial Pulse
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01G
Measure and Record
Apical Pulse
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R+BP = Vital Signs
TP
RESPIRATIONS
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RESPIRATIONS
Measuring respirations is one way of
checking on the respiratory system
4.01
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Respiratory System
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The Respiratory System
• Respiration means to breathe in
oxygen and breathe out carbon
dioxide
• Exchange of oxygen and carbon
dioxide necessary for life
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The Respiratory System
(continued)
• Process
–External respiration - oxygen and
carbon dioxide exchanged between
lungs and blood
–Internal respiration - oxygen and
carbon dioxide exchanged between
blood stream and cells
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•
•
•
•
•
•
•
The Respiratory System
Structure
Oral cavity – mouth
Pharynx – throat
Larynx - voice box
Trachea – windpipe
Bronchi - right and left
Bronchioles - smallest branches of
bronchi
Alveoli - air sacs covered with
capillaries
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The Respiratory System
Structure
(continued)
• Nose - lined with mucous
membrane
–air filtered by cilia
–mucous membrane
warms and moistens air
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The Respiratory System
Structure
(continued)
• Lungs
–right - 3 lobes
–left - 2 lobes
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The Respiratory System
Structure
(continued)
• Pleura – membrane that encloses
lungs
• Diaphragm - muscle that separates
the chest and abdomen
–contraction - draws air into lungs
–relaxation - forces air out of lungs
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Common Disorders of Respiratory
System
• URI – Upper Respiratory Infection infection of nose, throat, larynx,
trachea
• Pneumonia - inflammation or
infection of the lungs
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Common Disorders of Respiratory
System
(continued)
• Emphysema (Chronic Obstructive
Pulmonary Disease – COPD) –
alveoli become stretched and stiff
preventing adequate exchange of
oxygen and carbon dioxide
• Asthma – spasms of bronchial tube
walls causing narrowing of air
passages usually due to allergies
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Common Disorders of Respiratory
System
(continued)
• Allergy – reaction to substances that
leads to slight or severe response by
body.
• Influenza – highly contagious URI
• Pleurisy – inflammation of the pleura
surrounding the lungs
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Common Disorders of Respiratory
System
(continued)
• Bronchitis - inflammation of the
bronchi
• Lung cancer - malignant tumors in
the lungs that destroy tissue
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Changes in Respiratory System
Due To Aging
•
•
•
•
•
Lung tissue becomes less elastic
Respiratory muscles weaken
Number of alveoli decrease
Respirations increase
Voice pitched higher and weaker due
to changes in larynx
• Chest wall and structures become
more rigid
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Observations Of Respiratory System
•
•
•
•
Rate and rhythm of respirations
Respiratory secretions – character
Character of cough
Changes in skin color - pale or bluish
gray
• Temperature changes
• Difficulty breathing
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Observations Of Respiratory System
(continued)
• Color of sputum
• Complaint of pain in
chest, back, sides
• Shortness of breath
• Noisy respirations
• Sneezing
• Gasping for breath
• Anxiety
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Measuring Respirations
• Respiration – process
of taking in oxygen
and expelling carbon
dioxide from lungs
and respiratory tract
4.01
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Measuring Respirations
(continued)
Factors Affecting Rate
• Age
• Activity
level
• Position
• Drugs
4.01
• Sex
• Illness
• Emotions
• Temperature
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Measuring Respirations
(continued)
• Qualities of normal respirations
–12-20 respirations per minute
–Quiet
–Effortless
–Regular
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Measuring Respirations
(continued)
• Documenting respiratory rate
–Noted as number of inhalations
and exhalations per minute (one
inhalation and one exhalation
equals one respiration)
–Rhythm – regular or irregular
–Character: shallow, deep, labored
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01H
Count and Record
Respiration
4.01
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99
BP = Vital Signs
TPR+
BLOOD PRESSURE
4.01
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Blood Pressure
Measuring the pulse is one way of
checking on the circulatory system
4.01
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Measuring Blood Pressure
• Blood pressure is the force of blood
pushing against walls of arteries
–Systolic pressure: greatest force
exerted when heart contracting
–Diastolic pressure: least force
exerted as heart relaxes
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Factors Influencing Blood Pressure
•
•
•
•
•
•
•
•
4.01
Weight
Sleep
Age
Emotions
Sex
Heredity
Viscosity of blood
Illness/Disease
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Blood Pressure: Equipment
• Sphygmomanometer (manual)
–cuff - different sizes
–pressure control bulb
–pressure gauge – marked
with numbers
• aneroid
• mercury
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Blood Pressure: Equipment
(continued)
• Stethoscope
–magnifies sound
–has diaphragm
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Measuring Blood Pressure
Blood Pressure
Systolic
(top#)
Diastolic
(bottom #)
Normal
≤ 120
<80
Pre Hypertension
120-139
80-89
Hypertension Stage (1)
140-159
90-99
Hypertension Stage (2)
≥160
≥100
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Guidelines for Blood Pressure
Measurements
• Measure on upper
arm
• Have correct size
cuff
• Identify brachial
artery for correct
placement of
stethoscope
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Positioning of stethoscope
diaphragm
directly over the brachial artery increases ability to
hear the systolic and diastolic sounds
=
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Positioning of
stethoscope
diaphragm directly
over the brachial
artery increases
ability to hear the
systolic and
diastolic
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Guidelines for Blood Pressure
Measurements
(continued)
• First sound heard –
systolic pressure
• Last sound heard or
change - diastolic
pressure
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120
80
Systolic – Start hearing a Sound – Heart Muscle is Squeezing
Diastolic – Don’t hear sound anymore – Heart muscle does not
work during diastolic. This number is written down under the
systolic number.
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Guidelines for Blood Pressure
Measurements
(continued)
• Record - systolic/diastolic
• Resident in relaxed
position, sitting or lying
down
• Blood pressure usually
taken in left arm
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Guidelines for Blood Pressure
Measurements
(continued)
Do not measure blood
pressure in arm with IV,
A-V shunt (dialysis),
cast, wound, or sore
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Guidelines for Blood Pressure
Measurements
(continued)
• Apply cuff to bare
upper arm, not over
clothing
• Room quiet so blood
pressure can be heard
• Sphygmomanometer
must be clearly visible
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Blood Pressure: Reading Gauge
• Large lines are
at increments of
10 mmHg
• Shorter lines at
2 mm intervals
• Take reading at
closest line
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01I
Measure Blood Pressure
Manual
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01J
Combined Vital Signs
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Measuring
Height and Weight
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The resident’s weight,
compared with the height,
gives information about
his/her nutritional status
and changes in the medical
condition.
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Measuring Height And Weight
• Baseline measurement
obtained on admission
and must be accurate.
• Other measurements
obtained as ordered.
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Measuring Height And Weight
(continued)
• Height measurements
–Feet
–Inches
–Centimeters
• Weight measurements
–Pounds
–Ounces
–Kilograms
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Measuring Height and Weight
(continued)
• Reasons for obtaining height and
weight
–Indicator of nutritional status
–Indicator of change in medical
condition
–Used by doctor to order medications
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Special Case for Height
Measurement
• Residents who are contractured or
• Residents who cannot stand
• Must be measured using a tape
measure
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Measuring Height and Weight
(continued)
• Guidelines for weighing residents
–Use same scale
each time
–Have resident void,
remove shoes and
outer clothing
–Weigh at same time
each day
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Measuring Height and Weight
(continued)
• Scales
–Remain more accurate if moved as
little as possible.
–Various types of scales
• bathroom scale
• standing scale
• scales attached to hydraulic lifts
• wheelchair scales
• bed scales
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Training Lab Assignment
Engage in the Skill Acquisition Process for:
SKILL 4.01K
Measure Height
& Weight
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
END 
4.01
Understand vital signs, height, and
weight measurement skills.
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